Bringing a Wider Lens to Adolescent Mental Health: Aligning Measurement Frameworks with Multisectoral Actions.

The majority of mental health problems commonly emerge in adolescence, coinciding with a pivotal point in individual development that lays the foundations for future and intergenerational health [[1]Patton G.C. Olsson C.A. Skirbekk V. et al.Adolescence and the next generation.Nature. 2018; : 458Crossref PubMed Scopus (207) Google Scholar]. As a result, poor mental health in adolescence can impact on educational attainment, social relationships, societal productivity, and quality of life in the short and long term, and potentially across generations [[2]Patton G.C. Sawyer S.M. Santelli J.S. et al.Our future: A Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Abstract Full Text Full Text PDF PubMed Scopus (1843) Google Scholar,[3]Patel V. Saxena S. Lund C. et al.The Lancet Commission on global mental health and sustainable development.The Lancet. 2018; 392: 1553-1598Abstract Full Text Full Text PDF PubMed Scopus (1242) Google Scholar]. Yet, policy and practice responses to address poor adolescent mental health have been inadequate almost everywhere. Even in high income countries where there have been substantial investments in early clinical intervention, there has been little shift in the population prevalence of adolescent mental disorders [[4]Jorm A.F. How effective are ‘headspace’ youth mental health services?.Aust N Z J Psychiatry. 2015; 49: 861-862Crossref PubMed Scopus (21) Google Scholar]. There is a growing need to rethink mental health problems in this developmental window, both in strengthening treatment responses, and also investing in mental health promotion and prevention. Programmatic and policy actions must include efforts to measure the burden of adolescent mental health problems and their determinants so as to ensure that actions are responsive to varying and often complex needs. Furthermore, there is a need to both monitor the impact of any investments to ensure accountability, and to build the evidence base for effective actions [[2]Patton G.C. Sawyer S.M. Santelli J.S. et al.Our future: A Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Abstract Full Text Full Text PDF PubMed Scopus (1843) Google Scholar]. World Health Organization’s (WHO) widely accepted definition affirms that good mental health is more than the absence of disease. To be mentally healthy is to have “the capacity for thought, emotion and behaviour that enables individuals to realise their own potential, cope with normal stresses, to study or work productively, and to contribute to society” [[5]WHOPromoting mental health: Concepts, emerging evidence and practice. WHO, Geneva2004Google Scholar]. There are challenges however in translating this holistic definition into country policies and programing. If mental health is the embodiment of a life well lived, what does a scalable approach (across age, gender, and culture) include? Clinical guidelines (such as WHO’s mental health Gap Action Programme [mhGAP]) [[6]World Health OrganizationmhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health GAP Action Programme (mhGAP) - version 2.0. WHO, Geneva2016Google Scholar] focus on identifying and managing mental disorders through primary healthcare services. This approach helps to address disease [[3]Patel V. Saxena S. Lund C. et al.The Lancet Commission on global mental health and sustainable development.The Lancet. 2018; 392: 1553-1598Abstract Full Text Full Text PDF PubMed Scopus (1242) Google Scholar], but risks neglecting opportunities across sectors and within communities for broader mental health promotion and prevention that are perhaps most critical during adolescence, a time characterized by rapid change in interpersonal relationships, identity, health behaviors, and service access [[2]Patton G.C. Sawyer S.M. Santelli J.S. et al.Our future: A Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Abstract Full Text Full Text PDF PubMed Scopus (1843) Google Scholar]. Importantly, how do we operationalize a framework that recognizes that adolescent mental health is situated in a broader environment that includes family, peers, and community, all of which should be taken into account when working toward enhancing the psychosocial well-being of adolescents? And what are the opportunities for sectors outside of health, particularly education and social welfare? We propose a pragmatic conceptualization that enables a public health response, framing adolescent mental health around broader opportunities for intervention (Figure 1). The determinants of adolescent mental health include structural factors such as poverty, social inequality, marginalization, exposure to war and social upheaval, educational availability, and quality employment and training opportunities for older adolescents. Other determinants of mental health include norms (cultural, social, and gender), which are informal rules that govern behaviors and perceptions. Social norms of relevance to adolescent mental health include those related to adolescent autonomy, community participation and voice, gender identity, educational participation, sexual activity, substance use, and other risk behaviors, and those relating to exposure to violence. Shifting these norms and promoting positive mental health require a comprehensive approach that ensures legislation is enacted to protect young people from adverse exposures to violence, abuse, and incarceration, and increase access to treatment and support services. Further to adolescence being a developmental period shaped by structural determinants and norms [[7]Viner R.M. Ozer E.M. Denny S. et al.Adolescence and the social determinants of health.Lancet. 2012; 379: 1641-1652Abstract Full Text Full Text PDF PubMed Google Scholar], adolescents and their engagement as “social actors” can also powerfully shift determinants and norms for societies [[8]Diers J. Why the world needs to get serious about adolescents: A view from UNICEF.J Res Adolescence. 2013; 23: 214-222Crossref Scopus (26) Google Scholar]. Social and structural determinants shape the immediate social context of adolescents (including communities, peers, families) which can provide accessible opportunities for prevention of mental health problems. For example, recent high-quality school-based trials with a focus on positive school engagement and reducing bullying have demonstrated significant improvement in adolescent mental health [[9]Bonell C. Allen E. Warren E. et al.Effects of the learning together intervention on bullying and aggression in English secondary schools (INCLUSIVE): A cluster randomised controlled trial.The Lancet. 2018; 392: 2452-2464Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar,[10]Shinde S. Weiss H.A. Varghese B. et al.Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: A cluster-randomised controlled trial.The Lancet. 2018; 392: 2465-2477Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar]. Helping adolescents increase their capacity and skills for interreacting with their social context can also be important. Results from a meta-analysis also showed that universally delivered interventions with components that strengthen adolescent interpersonal skills, emotional regulation, substance use education, mindfulness, problem solving, assertiveness, and stress management can improve adolescent mental health outcomes and reduce risk behaviors [[11]Skeen S. Laurenzi C.A. Gordon S.L. et al.Adolescent mental health program components and behavior risk reduction: A meta-analysis.Pediatrics. 2019; 144: e20183488Crossref PubMed Scopus (59) Google Scholar]. Digital platforms have also emerged as an important focus of interventions. From staying connected to peers to learning new skills, accessing education and job opportunities, the internet and digital tools can promote and protect adolescents’ mental health and well-being. However, the increasing uptake of digital media can also heighten emotional risks from cyberbullying and other forms of online abuse. This rapidly shifting engagement with the world through digital platforms requires novel approaches to safeguarding our children and young people. Mental health problems are best conceptualized on a spectrum; at one extreme is positive mental health (or a positive sense of well-being) while at the other is mental health problems and disorders (or poor psychosocial well-being). Symptoms of mental health problems include disturbances in thought, emotion, behavior, and relationships with others, leading to disruption of daily life [[3]Patel V. Saxena S. Lund C. et al.The Lancet Commission on global mental health and sustainable development.The Lancet. 2018; 392: 1553-1598Abstract Full Text Full Text PDF PubMed Scopus (1242) Google Scholar]. Common mental disorders are often characterized by symptoms of unhappiness, loneliness, excessive worries, anxiety, sleep disturbance, and poor social functioning [[6]World Health OrganizationmhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health GAP Action Programme (mhGAP) - version 2.0. WHO, Geneva2016Google Scholar]. Adolescent mental disorders can be externalizing in nature (including conduct disorder and attention deficit disorder that have clear behavioral impacts) or more internalizing (such as depression and anxiety), and as such, be less conspicuous. All heighten risks for suicide and self-harm, especially in adolescence. Responsive health services [[12]WHO, UNAIDS. Global standards for quality health-care services for adolescents: A guide to implement a standards-driven approach to improve the quality of health care services for adolescents, Volume 1. Standards And Criteria; 2015, WHO, Geneva. Available at: https://apps.who.int/iris/bitstream/handle/10665/183935/9789241549332_vol1_eng.pdf?sequence=1&isAllowed=y16: website: https://data.unicef.org/topic/child-health/mental-health/mmap/. Accessed June 10, 2021.Google Scholar], characterized by accessibility, acceptability, and affordability (physical and financial enabling of confidential care), and developmentally appropriate healthcare, are foundational to addressing and managing mental health problems. Figure 1 highlights the opportunities for adolescent mental health promotion and prevention at a population level across sectors including health, education, and social welfare. It places structural determinants and the immediate social context side-by-side rather than the more traditional hierarchal configuration, reflecting the reciprocal relationships between the two. Many interventions for mental health promotion and prevention of mental disorders are packaged together (e.g., WHO-UINCEF Helping Adolescent Thrive), while also facilitating access to mental healthcare [[13]WHO. Helping adolescents thriveGuidelines on mental health promotive and preventive interventions for adolescents. WHO, Geneva2020Google Scholar]. This perspective focuses not only on intervention at the individual level, but places greater emphasis on the social ecology conducive to positive mental health that young people grow and live in, rooting mental health support within family and community systems. Structural determinants must be met with structural interventions. For example, young people of diverse sexual and gender identities are at risk of poor mental health, but this risk largely stems from the stigma and discrimination they experience rather than being intrinsically related to their identity [[14]Wilson C. Cariola L.A. LGBTQI+ youth and mental health: A systematic review of qualitative research.Adolesc Res Rev. 2019; 5: 187-211Crossref Scopus (74) Google Scholar]; interventions must therefore focus on shifting norms. The availability of appropriate data remains a foundation for broader action in adolescent mental health. Limited data collection efforts to date have focused on adolescent health risks (such as bullying), with sparse data on adolescent mental health outcomes [[15]Erskine H.E. Baxter A.J. Patton G. et al.The global coverage of prevalence data for mental disorders in children and adolescents.Epidemiol Psychiatr Sci. 2017; 26: 395-402Crossref PubMed Scopus (212) Google Scholar], and even less on key determinants, including norms. Efforts to develop validated adolescent measures of population mental health (including through United Nations Children's Fund’s Mental Health Among Adolescents at the Population Level initiative) [[16]UNICEF. Measurement of mental health among adolescents at the population level (MMAP), 2020. Available at: https://data.unicef.org/topic/child-health/mental-health/mmap/. Accessed June 10, 2021.Google Scholar] will enable the inclusion of high-quality measures in population or school-based surveys, enabling more nuanced understandings of risks and determinants. UN initiatives, including through the forthcoming UN Youth Health Report, are bringing an emphasis on inclusive social policies to address the structural determinants of mental health. These efforts will ultimately have benefits that extend beyond a reduction in mental disorders, optimizing the capabilities and quality of life of this generation. The authors would like to acknowledge Juliano Diniz de Oliveira and Brian Keeley for their contributions to this commentary. A/Prof Peter Azzopardi and Prof George Patton are supported by NHMRC Fellowships.